Laserfiche WebLink
Atea <br />Date <br />SITE MAP IN UNIT IV FILE, ADDRCSS: <br />WORK PLAN DATED:._ <br />Application Accepted By <br />Grout Inspection By <br />Destruction Ins cotton By <br />COMMENTS / CONO/IONS: <br />PERMIT / S GUEST 0 INVOICE <br />R7 I oi-Ivr of Auth <br />— . <br />10 0.4 0 kgrISSt7111 <br />9/27/00 <br />accoochment cicjc•-• <br />Dale <br />Dale <br />MAY-20-2002 03:19P FROM: TO: 19163834084 P:4/5 <br /> <br />moll• <br />WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 4e8-3449 <br />SITE <br />MITIGATION <br />UNIT IV <br /> <br />tpplication 13 hereby made to an <br />Joaquin County for a permit to construct and/or Install the work described. ThI3 application is made in compliance wl7i San <br />loaiquin County Development Tills, Chapter 9-1115_3 end the Standen:Is of San Joaquin County Public Health Seivicos. Environmental Heeiitt <br />ASse550e 6 <br />Nolovi moo*. City Cen Zip j_629 Porceiri t> 17 <br />4S 0 <br /> _Phonek <br />—-- <br />pangs <br />4•79, Lica C - 7 12b. Phone* L°9 " 3 46 c4itz" <br />Section .31 <br />1:1 DESTRUCTION (choose type below) <br />Li OVER-BORE <br />%PRESSURE GROLIT <br />Grout SpetifIcations: <br />'Othe r: <br />COMMENTS' <br />UND ON <br />ED PE M XP1R OM TE IS <br />NELL Locallon2j <br />N1OPERTY OvMer tj"crlf+ awsi , s Address <br />c.51 Contractor /() v-Oro fi real _ <br />COeStiltant Sub ContrzetorlAk.. &AA-46cm. Pk <br />GIS Cootolinate LI X Y <br />ANEW WELL 130RING ( CPT, GEOPROBE, HYDROPUNCH, NAND-AUGER, OTHER') ULM TO RE PERF9RMED: <br />AtzSOIL BORING 0 12)- 111 - 0 <br />WELL <br />t-4.0ecia Q• City W gzhi D.% <br />CAW <br />Addresa 3_.‘PiwieWts, Uai city <br />Township 4A) <br />A//14 <br />moNIT °RING <br />o EXTRACTION <br />0 VAPOR <br />(.) AIR SPAR4E <br />0 SOIL BORING <br />OTHER: <br />113 I QN. '•_"YPE <br />1:1 HOLLOW STEM <br />AIR HAMMER/DRIVEN <br />a MUD ROTARY <br />0 PUSH POINT <br />HAND AUGER <br />OTHER <br />comsTaLicrog OPE,CIPICATIONS <br />DIA. OF BOREHOLE__ . MULTIPLE CASINGS? fl YES D NO WELL CASING DIA. <br />CASING THICKNESS TYPE OF CASING D STEEL 13 PVC I] <br /> <br />EVTH OF GROUT SEAL <br />TREMIE TYPE TO BC USED: I) AUGERS 0 HOSE <br />GROUT SEAL PUMPED: D Yes 0 No <br />(NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />11 BOLTED TRAFFIC BOX or ()STOVE PIPE <br />(if YES, list speolficatiOns here): <br />GROUT SPECIFICATIONS: <br />APPROX BORING DEPTH <br />CONDUCTOR CASING PROPOSED? <br />'COMMENTS: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br />CALL TH,UNIT IV I <br />CTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />I here eV that I have <br />ared this application and that the work will be done in accordance with San Joaquin <br />Co ty Ordlj nces, <br />Regulations, and ail applicable California State Laws, <br />Sig <br />TMerCompany Nv_O___20.1- °R ell3.`"-I <br /> <br />02te .6 _ 7.6 ..0.z. spoEiao,A.4, .734' <br />l'i°VC WE- DE 12t1EN"im•m-LL^'L.-"...'iS °NI LY. <br /> Print